Disparities in Amputee Care
Written by Mahfuz Mahin Dewan, DO
TLDR: Amputee care utilizes an interdisciplinary approach that addresses the physical and psychological needs of individuals who have undergone limb amputation. It includes residual limb management, phantom limb pain control, prosthetic fitting and rehabilitation, and psychological support. Disparities in amputee care exist in access to care, mental health support, and development of secondary health conditions. Socioeconomic factors and individual characteristics such as race, gender, and age underlie these disparities. Providing easy access to rehabilitation services is crucial for ensuring comprehensive, patient-centered care to address amputees' physical and psychosocial needs.
Overview:
Disparities include:
Access to prostheses and rehabilitation facilities following an amputation.
Clinical outcomes improve when patients stay at a rehabilitation facility vs returning home following their amputation, with even more improvement when staying at an inpatient rehabilitation facility vs a skilled nursing facility (Pasquina et al., 2015). However, cost is a huge barrier; 20% of nonmilitary amputees reported an unmet need for rehabilitation services due to inability to pay (Pasquina et al., 2015).
Those who are uninsured also face access barriers. Uninsured amputees had an improved physical quality of life when adding a free monthly interdisciplinary clinic to their care (Sevigny et al., 2022).
Recognition of mental health issues and subsequent support.
Levels of anxiety and depression are significantly higher in those with amputations than in the general population (Mckechnie & John, 2014). Studies show those with access to specialized care programs may have mental health issues recognized and referred more effectively than those without access to such programs (Pasquina et al., 2015).
Inadequate care of secondary health conditions.
These include osteoarthritis, osteoporosis, and back pain (Gailey et al., 2008). Amputees also face an increased morbidity and mortality from cardiovascular events (Naschitz et al., 2008).
Of those with amputations, the following groups face specific issues:
Women: A smaller percentage of women with limb loss remained employed following their amputation(s) than their male counterparts (Pasquina et al., 2015). Additionally, those who are pregnant can face mobility challenges with ill-fitting prosthetics and gait aids (Bateman et al., 2022).
Low-Income Individuals: Those with an income at or near the poverty line are 2.5 to 3 times as likely as their peers who are not in poverty to perceive barriers in their access to work or community life (Pasquina et al., 2015)
Black Americans: They are four times more likely to undergo an amputation and 2.5 times as likely to have a second lower limb amputation than non-Hispanic white Americans, even when controlling for factors such as age, sex, and diabetes severity (Pasquina et al., 2015). They also face reduced survival following amputation (Schutze et al., 2021).
Hispanic Americans: They are 1.5 times as likely to suffer an amputation as non-Hispanic white Americans (Pasquina et al., 2015).
What is part of the solution?
As amputation rates are expected to double by 2050 with increased incidence of predisposing factors such as peripheral vascular disease and diabetes, the challenges our health care system faces with amputee care is only expected to increase (Pasquina et al., 2015). Here are some areas physicians can improve upon for our patients with amputations:
Amputee care starts before the amputation; be transparent with what the patient can expect after the procedure and address their questions/concerns.
Referral to a rehabilitation facility. Patients who undergo amputations at a trauma center are 1.5 times more likely to be sent to an inpatient rehabilitation facility than those treated at hospitals without trauma centers (Pasquina et al., 2015).
Increasing access to rehabilitation services, such as prostheses fitting & training. Prosthetic usage has been associated with higher quality of life, decreased phantom pain, and reduction of secondary health conditions (Pasquina et al., 2015).
Encouraging and engaging patients in their pre- and post-amputation care to provide a more patient-centered approach. This can help identify the unique needs your patients face and help to develop structured rehabilitation programs for them.
Recognize & understand the disparities that exist will help you advocate and provide preventative care for your patients. Learn more at Amputee Coalition’s website https://www.amputee-coalition.org/
References: Bateman, E., Frengopoulos, C., Viana, R., & Payne, M. (2022). Pregnancy after amputation. American Journal of Physical Medicine & Rehabilitation, 101(11), 1066-1075. https://doi.org/10.1097/phm.0000000000001949 Chamlian, T., Bonilha, M., Macêdo, M., Rezende, F., & Leal, C. (2012). Prevalence of phantom pain among amputees at lar escola são francisco. Acta Fisiátrica, 19(3), 167-170. https://doi.org/10.5935/0104-7795.20120026 Pasquina, P., Carvalho, A., & Sheehan, T. (2015). Ethics in rehabilitation: access to prosthetics and quality care following amputation. The Ama Journal of Ethic, 17(6), 535-546. https://doi.org/10.1001/journalofethics.2015.17.6.stas1-1506 Yu, J., Lam, K., Nettel-Aguirre, A., Donald, M., & Dukelow, S. (2010). Incidence and risk factors of falling in the postoperative lower limb amputee while on the surgical ward. Pm&r, 2(10), 926-934. https://doi.org/10.1016/j.pmrj.2010.06.005Feinglass, J., Abadin, S., Thompson, J., & Pearce, W. (2008). A census-based analysis of racial disparities in lower extremity amputation rates in northern illinois, 1987-2004. Journal of Vascular Surgery, 47(5), 1001-1007. https://doi.org/10.1016/j.jvs.2007.11.072 Mckechnie, P. and John, A. (2014). Anxiety and depression following traumatic limb amputation: a systematic review. Injury, 45(12), 1859-1866. https://doi.org/10.1016/j.injury.2014.09.015 Sevigny, M., Philippus, A., Payne, L., & Gerber, D. (2022). The impact of a structured rehabilitation program for uninsured individuals.. Rehabilitation Psychology. https://doi.org/10.1037/rep0000417Tirrell, A., Kim, K., Rashid, W., Attinger, C., Fan, K., & Evans, K. (2021). Patient-reported outcome measures following traumatic lower extremity amputation: a systematic review and meta-analysis. Plastic and Reconstructive Surgery Global Open, 9(11), e3920. https://doi.org/10.1097/gox.0000000000003920Pasquina PF, Hendershot BD, Isaacson BM. Secondary health effects of amputation. In: Atlas of Amputations and Limb Deficiencies. 4th ed. Rosemont, IL: American Academy of Orthopedic Surgeons. In press.Sheehan TP, Gondo GC. Impact of limb loss in the United States. Phys Med Rehabil Clin N Am. 2014;25(1):9-28.Shutze, W., Gable, D., Ogola, G., Yasin, T., Madhukar, N., Kamma, B., Alniemi, Y., Eidt, J.,Sex, age, and other barriers for prosthetic referral following amputation and the impact on survival. (2021). Journal of Vascular Surgery, 74(5), 1659-1667. https://doi.org/10.1016/j.jvs.2021.05.025.Gailey R, Allen K, Castles J, Kucharik J, Roeder M. Review of secondary physical conditions associated with lower-limb amputation and long-term prosthesis use. J Rehabil Res Dev. 2008;45(1):15-29. doi:10.1682/jrrd.2006.11.0147Naschitz JE, Lenger R. Why traumatic leg amputees are at increased risk for cardiovascular diseases. QJM. 2008;101(4):251-259. doi:10.1093/qjmed/hcm131